Flea Bytes: Post-ERCP Pancreatitis

Incidence of post-ERCP pancreatitis is 3 to 5%, but can be as high as 16%

Mechanisms:
  • Manipulation of the papilla or thermal injury produces papillary edema and obstruction of the pancreatic duct causing pancreatitis.
  • Hydrostatic injury from overinjection of water or saline into the pancreatic duct
  • Presence of a foreign material in the pancreatic duct stimulates activation of proteolytic enzymes.
  • Reflux of intestinal enzymes into the pancreatic duct.
  • Bacterial translocation.
Risk Factors
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Prevention:
A meta-analysis of 912 patients, found that patients who received NSAIDs were 64% less likely to develop pancreatitis and 90% less likely to develop moderate-severe pancreatitis.  A number needed to treat (NNT) to prevent 1 episode of pancreatitis: 15.
Then an RCT of single dose rectal indomethacin or placebo in 602 patients was performed which showed PEP rates of 9.2% versus 16.9%. the use of rectal indomethacin was associated with a 7.7% absolute risk reduction (NNT 13) and a 46% relative risk reduction in PEP. A more recent trial with conflicting data – likely due to the patient population selected and use of pancreatic duct stents.
Rectal indomethacin should be considered in high risk patients.
Protease inhibitors have shown some promise, they are costly, require extremely high NNTs to prevent a single episode of PEP (gabexate 33 and ulinastatin 29)
Octreotide shows promise in preventing PEP.
Employ a wire-guided cannulation technique
Implement alternative technique early in the case in the event of difficult biliary cannulation
References:
The “Scope” of Post-ERCP Pancreatitis by Parth J. Parekh, MD; Raj Majithia, MD; et al. Mayo Clin Proc. 2016
Keywords:
#GI #Pancreatitis #ERCP #post-ERCP #indeomethacin #prevention
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